86R13547 PMO-D
By: Lucio III H.B. No. 4442
A BILL TO BE ENTITLED
AN ACT
relating to health benefit coverage for general anesthesia in
connection with certain pediatric dental services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1367, Insurance Code, is amended by
adding Subchapter G to read as follows:
SUBCHAPTER G. PEDIATRIC DENTISTRY
Sec. 1367.3001. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical, surgical, or dental expenses incurred as a
result of a health condition, accident, or sickness, including an
individual, group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or an
individual or group evidence of coverage or similar coverage
document that is issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this subchapter applies
to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
(c) This subchapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1367.3002. EXCEPTIONS. (a) This subchapter does not
apply to:
(1) a plan that provides coverage:
(A) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(B) as a supplement to a liability insurance
policy;
(C) for credit insurance;
(D) only for vision care;
(E) only for hospital expenses; or
(F) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section
1395ss(g)(1));
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that the
policy provides benefit coverage so comprehensive that the policy
is a health benefit plan as described by Section 1367.3001.
(b) This subchapter does not apply to an individual health
benefit plan issued on or before March 23, 2010, that has not had
any significant changes since that date that reduce benefits or
increase costs to the individual.
Sec. 1367.3003. COVERAGE FOR GENERAL ANESTHESIA. A health
benefit plan that provides coverage for dental services may not
exclude from coverage general anesthesia services in connection
with dental services provided to a covered individual who is:
(1) younger than 18 years of age; and
(2) unable to undergo the dental service in an office
setting or under local anesthesia due to a documented physical,
mental, or medical reason determined by the individual's physician
or by the dentist providing the dental care.
Sec. 1367.3004. CONDITIONAL EXCEPTION. This subchapter
does not apply to a qualified health plan if a determination is made
under 45 C.F.R. Section 155.170 that:
(1) this subchapter requires the plan to offer
benefits in addition to the essential health benefits required
under 42 U.S.C. Section 18022(b); and
(2) this state is required to defray the cost of the
benefits mandated under this subchapter.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. Subchapter G, Chapter 1367, Insurance Code, as
added by this Act, applies only to a health benefit plan that is
delivered, issued for delivery, or renewed on or after January 1,
2020.
SECTION 4. This Act takes effect September 1, 2019.